I met a man ten years ago who was one of the many victims of the last Conservative government’s NHS reforms. The 61-year-old had been ill for two and a half years, and on a waiting list for a heart operation for more than a year of that. In that period his health had declined until he was unable to walk more than a few hundred yards. The man, who neither drank nor smoked, had lost his job, sold his car and had to go on benefits, which he found degrading. His was a tale of delays and delays which used to be all too familiar in the NHS: tight chest, three-month wait for first hospital appointment, tests, delay, heart attack, six-month wait for angiogram, six-month wait to see heart surgeon. And then a year longer, on a waiting list for an operation. I don’t know if he ever had the operation and I do not know whether he is still alive.
The problem this patient faced was what health authority managers called a “strategic planning lag”. It developed because the Conservative government had handed power to GP fundholders. Before that, the regional health authority would monitor the number of patients booked in for angiograms and plan on the assumption that half of them would need surgery. When fundholding was introduced, the system broke down; no one was planning strategically any longer. It is no exaggeration to say that, as a result, many people died earlier than they need have.
Alarm bells
Now a new Conservative government is doing the same thing again – only faster, and harder. Every GP in England is to be forced to take over commissioning within two years, and strategic health authorities will be abolished a year later. Rarely can a minister have conceived of a policy that has so alarmed so many professionals from every corner of the health service, and in every political corner: from managers and GPs to right-wing think tanks and health advocates. Even the chief executive of the NHS has sounded a note of caution.
The Secretary of State for Health, Andrew Lansley, plans to push through, in less than two years, the biggest structural reform since the creation of the NHS. The NHS Alliance, a group of doctors and managers that champions GP commissioning, has warned that “only about 5 to 10 per cent of GPs are ready to take on hard budgets to buy care within the next few months. Perhaps 50 per cent will be within 18 months. But others will take longer.”
The words – commissioning, fundholding, strategic – are impersonal, but the reality is life and death. The absence of any concerted political campaign against these plans shows what a terribly undemocratic moment this is for Britain: the Lib Dems snuggling up to the Conservatives and Labour engaged in meetings with itself. All patients were treated within 18 weeks by the time Labour lost office, an achievement the party is allowing the Conservatives to wreck with barely a squeak. Labour achieved it not by “marketisation” – the introduction of private-sector treatment centres or foundation hospitals and purchaser/provider splits – but by a huge funding increase and the imposition of targets that the Conservativesare also now scrapping. But Labour has laid the foundations for the Conservatives to wage this ideological war on the NHS.
I write not as an ideologue. The NHS can be arrogant, bureaucratic, wasteful, baffling and paternalistic. I recently visited an old friend who had the misfortune to stay three weeks in hospital. She spent that time in a temporary ward designed for discharge only, housing about 40 patients. There were no windows, no television, no phone and the patients shared a shower and toilet with plasterboard walls that were damp and flimsy. Mould leaked out from behind the taps. There were the elderly, the foreign and the poor – a vocal middle-class person would have been out of there in days. The NHS is not even an equitable service. If private-sector competition can force improvements, good.
Private practice
But how is Lansley’s plan to achieve this? The point of devolving commissioning to GPs is to enable GPs – and, in theory, their patients – to drive improvements by opening up the market to alternative private-sector providers. GP fund-holders in the 1990s showed that they could cut pharmacy costs and waiting times. However, they did this mostly by getting quicker treatment from NHS hospitals. For all the noise about the introduction of competition in the NHS under Labour, the private sector remained tiny: by 2008, only 1.79 per cent of elective operations was conducted by independent-sector treatment centres, and that was despite generous contracts to encourage them.
When the chairman of the British Medical Association suggested this month that GPs might choose to stick with NHS providers, Lansleyresponded that patient choice would force them to consider other providers. Yet there is no evidence that patients want to choose which hospital treats them, or that they have the information they need to do so. They rely on their GPs for that. Analysis by Ipsos MORI and the King’s Fund is clear: what patients want is to be treated with respect, a clean hospital, good pain control and to be involved in decisions about their care – but not decisions about where they are treated. A King’s Fund survey last year found less than a third of patients considered choice of hospital or doctor to be important. Patients are not going to drive the process of opening new private-sector units.
What patients will do is shop around for the GP who offers the “most” care. They might not want to choose a hospital, but they’ll know how to choose a GP. In Germany, unfettered patient choice forced the introduction of gatekeepers and charges. Is that where the Conservatives are heading? Probably. Where is the opposition when you need it?
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